Prostate adenocarcinoma presenting as a large supraclavicular mass

Metastatic prostate cancer is classically associated with bony or pelvic lymphatic metastasis. This case review represents an unusual case of prostate cancer presenting with a large left supraclavicular neck mass.     

Metastatic adenocarcinoma in the baboon

An adenocarcinoma of undetermined origin, with metastasis to the skeletal system, occurred in a 27 year-old castrated male baboon (Papio species).     

Metastatic Hurthle Cell Carcinoma of the thyroid presenting as a Breast Lump: A Case Report

Background

Hurthle cell carcinoma of the thyroid is a rare form of thyroid cancer. It may present as a low grade tumour or can present as a more aggressive metastatic carcinoma. Hurthle cell carcinoma has the highest incidence of metastasis among all differentiated thyroid cancers. Most commonly haematogenous spread to lungs, bones and brain, however spread to regional lymph nodes is not uncommon. The breast is a rare site for metastasis from extramammary sources. We present the first case of breast metastasis from Hurthle cell carcinoma of the thyroid.

Case presentation

We report a 77 year old lady who had total thyroidectomy and bilateral neck dissection followed by radiotherapy for a high grade metastatic Hurthle cell carcinoma of the thyroid. Ten months later she presented to the breast clinic with left breast lump and a lump at the left axilla. Fine needle aspiration cytology of the lumps and histology after wide local excision of the breast lump confirmed metastatic Hurthle cell carcinoma.

Conclusion

The presence of breast lumps in patients with history of extramammary cancer should raise the possibility of metastasis.

     

Cardiac tamponade as the initial manifestation of systemic lupus erythematosus in a young female patient

A 21-year-old woman with a medical history of epilepsy was admitted to our hospital because of progressive chest pain and dyspnoea for a few days. The chest pain fluctuated with breathing and was aggravated in a supine position. On physical examination a very dyspnoeic woman with a blood pressure of 105/65 mmHg and a heart rate of 140/min was seen. Pulsus paradoxus was absent and the jugular venous pressure was not increased. Besides sinus tachycardia, the electrocardiogram was normal.     

Teaching cases: Pulmonary lymphangitic carcinomatosis as a primary manifestation of colon cancer in a young adult

Abstract: Pulmonary lymphangitic carcinomatosis is a metastatic lung disease characterized by diffuse spread of the tumour to the pulmonary lymphatic system. We describe the case of a 31-year-old woman who initially received a diagnosis of sarcoidosis based on the results of imaging studies. However, results of a transbronchial biopsy led to the diagnosis of pulmonary lymphangitic carcinomatosis from metastatic colon cancer.The case: A 31-year-old woman presented to her primary care provider with a nonproductive cough and shortness of breath, which she had experienced intermittently for 1 month. She had no fever, chills or night sweats. She had type 1 diabetes mellitus and hypertension. The patient had experienced multiple miscarriages and was 1 month post partum. She had a 10-pack-year history of smoking. Her father and maternal grandfather both had colon cancer, which, in her father, had been diagnosed after his death at the age of 45. The patient received a diagnosis of exacerbated chronic obstructive pulmonary disease, which was treated with a short course of corticosteroids and broad-spectrum antibiotics. Her condition did not improve.Two months later, the patient presented to the emergency department with dyspnea. A radiograph of her chest showed interstitial lung disease, thickening of the right paratracheal region and hilar prominence. A computed tomography (CT) scan of her chest revealed extensive paratracheal, subcarinal and para-aortic lymphadenopathy. It also showed diffuse consolidation with a nodular pattern throughout the lungs, particularly in the upper lobes and the lower left lobe. She received a diagnosis of sarcoidosis, which her primary care physician treated with corticosteroids. Her symptoms abated, but less than 1 week later, her condition worsened. Oxygen therapy was started at home.A respirologist saw the patient 6 months after the onset of her symptoms. She still had exertional dyspnea and a nonproductive cough without hemoptysis. She had lost 20 pounds in the 5 months preceding the visit. She had tachypnea and tachycardia, and was normotensive and afebrile. She did not have enlarged lymph nodes, skin changes or peripheral edema.Examinations of the patient''s abdomen and heart sounds were unremarkable. We heard rhonchi and crackles in the base of both lungs. A radiograph of her chest showed diffuse interstitial and septal thickening in both lungs (Figure 1). A CT scan showed large nodular areas, ground-glass opacities and thickened interlobular septa with interstitial lung disease (Figure 2).Open in a separate windowFigure 1: Chest radiograph of a 31-year-old woman showing diffuse interstitial and septal thickening (arrow) in both lungs.Open in a separate windowFigure 2: Computed tomography scan showing nodular thickening of interlobular septa (white arrow), seen as polygonal arcades with thickened and nodular limbs, and ground-glass opacities (black arrows).Results of a transbronchial biopsy showed a moderate to poorly differentiated adenocarcinoma. Immunohistochemical studies of the biopsy specimen showed a pattern of staining consistent with metastatic adenocarcinoma most suggestive of a primary origin in the colon. A colonoscopy showed a mass in her proximal sigmoid colon, and biopsy results confirmed the mass to be a moderately differentiated adenocarcinoma. A bone scan showed multiple tomours in her thorax and lumbar spine.The patient was admitted to hospital for chemotherapy (FOLFOX4, a regimen of oxaliplatin, leucovorin and 5-fluorouracil). She was transferred the next day to the intensive care unit because of worsening respiratory distress, necessitating mechanical ventilation. The chemotherapy was continued; however, the patient died of respiratory failure 11 days after admission to hospital.Pulmonary lymphangitic carcinomatosis occurs in 6%–8% of patients with pulmonary metastases.¹ The spread of tumour cells to the pulmonary lymphatic system or the adjacent interstitial tissue results in thickening of the bronchovascular bundles and septa. Desmoplastic reaction due to proliferation of neoplastic cells, and lymphatic dilation by edema fluid or tumour secretions contribute to this interstitial thickening. Spread of the neoplasm outside the interstitium and lymphatic spaces into the adjacent parenchyma can result in a nodular pattern.² Although virtually any metastatic neoplasm can cause pulmonary lymphangitic carcinomatosis, the common locations of the primary tumour are the breasts, stomach, lungs, pancreas and prostate^1,3 (Open in a separate windowPatients with pulmonary lymphangitic carcinomatosis often present with breathlessness and a nonproductive cough. As with our patient, the onset of pulmonary symptoms may precede diagnosis of the primary tumour; however, the frequency of this presentation is unknown. Although chest radiographs appear normal for 30%–50% of patients with histologically proven disease,² pulmonary lymphangitic carcinomatosis has several characteristic changes that can be observed on radiographs (Box 1). Transbronchial biopsy is required for a definitive diagnosis.Open in a separate windowBox 1Pulmonary lymphangitic carcinomatosis can mimic sarcoidosis radiologically. Nodular thickening and ground-glass attenuation are seen in 30%–60% of patients with sarcoidosis. The nodules in sarcoidosis mainly involve central regions of the middle and upper lobes of the lungs. In contrast, changes usually occur in the lower lobes in pulmonary lymphangitic carcinomatosis. Although imaging studies may suggest sarcoidosis, the diagnosis should be confirmed by biopsy results indicating noncaseating granulomas and by the exclusion of other causes of granulomatous disease. Rapid onset and progression of symptoms, asymmetrically enlarged lymph nodes, predominant disease in the lower lobes of the lungs and lack of response to steroids within 2–4 weeks also should alert clinicians to a diagnosis other than sarcoidosis. Thickening of the interlobular septa and peribronchovascular interstitium without a nodular pattern may be seen in other conditions, such as pulmonary edema and idiopathic pulmonary fibrosis.²Although the diagnosis was delayed for our patient, an earlier diagnosis may not have altered the outcome because of the condition''s extremely poor prognosis in most cases. Less than half of patients with pulmonary lymphangitic carcinomatosis who present with respiratory symptoms survive for 3 months.¹ However, platinum-based chemotherapy has led to transient remissions in some cases.⁴Although our patient did not undergo genetic testing, her young age at presentation and strong family history of colon cancer led to a diagnosis of hereditary nonpolyposis colorectal cancer. This condition accounts for 2%–3% of colorectal cancers and is the most common form of hereditary colorectal cancer.⁵ It is characterized by an early onset, with an average age at diagnosis of about 45 years and the presence of tumours predominantly on the right side of the colon. Patients with this condition are also at increased risk of having more than 1 primary colorectal tumour at the time of diagnosis (synchronous neoplasms) and of having another primary tumour after successful treatment of the index tumour (metachronous carcinoma). Patients with this condition are more likely than others of the same age and sex to experience tumours of the endometrium, small bowel, stomach, renal pelvis ureter and ovaries. Skin lesions, including carcinomas and nonmalignant lesions such as sebaceous adenomas and keratoacanthomas, are also more common among these patients.⁶Our patient had unusual features of pulmonary lymphangitic carcinomatosis, including involvement of the sigmoid colon and metastatis to the lungs and spine without liver involvement. This presentation is seen in only about 9% of rectal cancers.⁷ If hereditary nonpolyposis colorectal cancer is suspected, a biopsy of the tumour and genetic testing should be carried out to identify mutations. Once identified, relatives at high risk for colorectal cancer should be counselled and screened for these mutations. Those who carry the mutations should have a colonoscopy every 2 years starting at age 20–25.⁶Anish Thomas MD Robert Lenox MD Department of Medicine State University of New York Syracuse, New York     

Appendiceal adenocarcinoma presenting as left-sided large bowel obstruction,a case report and literature review

Background

appendiceal tumours are rare, they may be encountered unexpectedly in any acute or elective abdominal operation, many of these tumours are not appreciated intraoperatively and are diagnosed only during formal histopathological analysis of an appendicectomy specimen. Herein we present a case of appendiceal adenocarcinoma presenting as left-sided large bowel obstruction, we also review the literature of unusual presentations of appendiceal tumours.

Case Presentation

we report a case of left sided large bowel obstruction found to be secondary to an appendiceal adenocarcinoma. The patient presented with abdominal pain, distension and constipation, CT scan showed large bowel obstruction thought to be due to a sigmoid tumour, on laparotomy the appendix was also noted to be abnormal. A low Hartman's was performed with en-bloc total hysterectomy and bilateral salpigo-oophorectomy. A separate ileocaecal resection with end ileostomy was also performed, pathology specimens showed that the primary neoplasm was the appendix with metastasis to the distal sigmoid.

Conclusion

appendiceal tumours are rare, they usually present as acute appendicitis, other presentations are far less common.

     

Acute watery diarrhea as the initial presenting feature of a pheochromocytoma in an 84-year-old female patient

We report the case of an 84-year-old woman who was initially admitted to the emergency room of our institution for frank dehydration caused by acute and severe secretory diarrheas along with acidosis and hypokalemia. After extensive gastrointestinal investigations, the etiology of the diarrhea remained unclear. Because clinical symptoms and ionogram parameters worsened, despite intravenous fluids and electrolyte replacement, an abdominal CT scan was performed and unexpectedly revealed a 4.5-cm mass in the right adrenal gland. Several separate 24-hour urine catecholamines were shown to be highly elevated. The diagnosis of pheochromocytoma was confirmed by MIBG scintigraphy and MRI. Before the admission, the patient never experienced symptoms suggestive of pheochromocytoma, except dry mouth and fear of impending death on several occasions. After 2 weeks, the diarrhea stopped abruptly and spontaneously without specific medication but after adequate rehydration. The patient subsequently underwent surgical removal of the adrenal medullary mass. Postoperatively, urinary catecholamines returned to normal values. Immunohistochemical study of the tumor confirmed the diagnosis of pheochromocytoma and revealed the presence of VIP-positive cells organized as islets in scattered areas of the tissue. This case illustrates the protean mode of presentation of pheochromocytoma, as well as the ability of medullary neural crest-derived cells to produce various neuropeptides potentially responsible for a large variety of symptoms.     

Mammary adenocarcinoma in a young female hypercholesterolemic rat.

Pathological examination of a 12-week-old female rat with hypercholesterolemia revealed mammary adenocarcinoma. Grossly, one grayish-white nodule was found in the hypoderm near the right posterior mammary gland. Histologically, the nodule was composed of variable-sized epithelial cells which lined the tubules and ducts in one to several layers, accompanied by proliferation of connective tissue in the stroma. Mitotic figures, necrosis and hemorrhage appeared frequently throughout the lesion. The tumor cells had invaded the surrounding muscular tissue.     

GNG4, as a potential predictor of prognosis,is correlated with immune infiltrates in colon adenocarcinoma

The tumour microenvironment (TME) and immunosuppression play an important role in colon cancer (CC) metastasis, which seriously affects the prognosis of CC. G protein subunit gamma 4 (GNG4) has been shown to participate in tumour progression and the tumour mutation burden (TMB) in colorectal cancer. However, the effect of GNG4 on the CC TME and immunology remains elusive. Weighted gene coexpression network analysis (WGCNA) was employed for screening aberrantly expressed genes associated with the immune score, and GNG4 was then selected through prognostic and immune correlation analysis. Based on RNA sequencing data obtained from the TCGA and GEO databases, the expression pattern and immune characteristics of GNG4 were comprehensively examined using a pan-cancer analysis. Upregulation of GNG4 was linked to an adverse prognosis and immune inhibitory phenotype in CC. Pan-cancer analysis demonstrated higher GNG4 expression in tumours than in paired normal tissue in human cancers. GNG4 expression was closely related to prognosis, TMB, immune checkpoints (ICPs), microsatellite instability (MSI) and neoantigens. GNG4 promoted CC cell proliferation, migration and invasion and participated in immune regulation in the TME. Significantly, GNG4 expression was found to negatively correlate with tumour-infiltrating immune cells, ICP, TMB and MSI in CC. GNG4 expression predicted the immunotherapy response in the IMvigor210 cohort, suggesting that GNG4 could be used as a potential biomarker in CC for prognostication and immunology. Moreover, the expression of GNG4 predicted the immunotherapy response of ICB in CC.     

Phaeohyphomycosis caused by Alternaria infectoria presenting as multiple vegetating lesions in a renal transplant patient

The genus Alternaria is one of the most common black moulds and appears to be increasing as a causative agent of subcutaneous phaeohyphomycosis, particularly among immunosuppressed patients. A 53-year-old patient who had received a kidney transplant presented with multiple verrucous lesions on the distal extremities. Positive histopathology and cultures, in addition to rDNA ITS region sequencing, identified the fungal isolate as Alternaria infectoria. Oral itraconazole was administered for 10 months. A follow-up at 15 months demonstrated no signs of infection. Clinical manifestations of cutaneous alternariosis vary significantly and only a few cases have been described in the literature. Although optimal treatment options remain controversial, this case of phaeohyphomycosis was successfully treated with itraconazole monotherapy.     

Characteristics of thymidylate synthase purified from a human colon adenocarcinoma

Thymidylate synthase has been purified greater than 4000-fold from a human colon adenocarcinoma maintained as a xenograft in immune-deprived mice. In this disease, the enzyme is an important target for the cytotoxic action of 5-fluorouracil, which is influenced by the reduced folate substrate CH2-H4PteGlu. Due to the importance of this interaction, and the existence in cells of folate species as polyglutamyl forms, the interaction of folylpolyglutamates with thymidylate synthase was examined. Polyglutamates of PteGlu were used as inhibitors, and the interaction of CH2-H4PteGlu polyglutamates as substrates or in an inhibitory ternary complex were also examined. Using PteGlu1-7, Ki values were determined. A maximal 125-fold decrease in Ki was observed between PteGlu1 and PteGlu4; further addition of up to three glutamyl residues did not result in an additional decrease in Ki. Despite the increased binding affinity of folypolyglutamates for this enzyme, no change in the Km values for either dUMP (3.6 microM) or CH2-H4PteGlu (4.3 microM) were detected when polyglutamates of [6R]CH2-H4PteGlu were used as substrates. Product inhibition studies demonstrated competitive inhibition between dTMP and dUMP in the presence of CH2-H4PteGlu5. In addition, CH2-H4PteGlu4 stabilized an inhibitory ternary complex formed between FdUMP, thymidylate synthase, and CH2-H4PteGlu4. Thus the data do not support a change in the order of substrate binding and product release upon polyglutamylation of CH2-H4PteGlu reported for non-human mammalian enzyme. This is the first study to characterize kinetically thymidylate synthase from a human colon adenocarcinoma.